High Impact HIV Prevention Services and Best Practices David W. Purcell, JD, PhD Deputy Director for Behavioral and Social Science Division of HIV/AIDS Prevention Centers for Disease Control and Prevention HIV Prevention Project Annual Technical Support Meeting December 4, 2013 Washington, DC Centers for Disease Control and Prevention Division of HIV/AIDS Prevention
Disclosures The following people have no relevant financial, professional or personal relationships to disclose: Faculty: David W. Purcell, JD, PhD CNE Program Planner(s): Melanie Steilen, RN, BSN, ACRN Iris Stendig-Raskin, MSN, CRNP, WHNP-BC CNE Program Reviewer: Iris Stendig-Raskin, MSN, CRNP, WHNP-BC There are no commercial supporters of this activity.
Overview HIV Epidemic in U.S. Changing Times What Do We Do Now? High Impact Prevention (HIP) Program and Policy Examples of HIP
HIV Epidemic in US
HIV Prevalence and Incidence United States, 1980-2010 Number of people living with HIV has grown because incidence is relatively stable and survival has increased Hall HI et al. JAMA 2008 Aug 6;300(5):520-9; Prejean J et al PLoS One 2011;6(8):e17502; MMWR 2012 Mar 2;61(8):133-8.
1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 Number Estimated HIV Transmission Rate 1,200,000 100 1,000,000 Number living with diagnosed HIV infection Transmission rate 80 800,000 600,000 400,000 200,000 60 40 20 Rate, per 100 0 0 Year CDC. MMWR 2012; 61 (Suppl; June 15, 2012): 57-64. Holtgrave et al. Updated Annual HIV Transmission Rates in the United States, 1978-2006. J Acquir Immune Defic Syndr 2009; 50 (2): 236-38; Holtgrave et al. HIV Transmission Rates in the United States, 2006-2008. The Open AIDS Journal 2012; 6:20-22.
Estimated New HIV Infections by Route of Transmission, 2010 Two-thirds of new HIV infections occur among MSM
Health Inequity African Americans 8 times and Latinos 3 times more likely to have HIV than whites Women estimated to be diagnosed with HIV in their lifetime ranges from about 1 in 32 among African American women to 1 in 526 among white or Asian women HIV prevalence is associated with population density, region of residence, poverty, education, employment, and homelessness MSM >40 times more likely than other men and women CDC, HIV Surveillance Report, 2009; www.cdc.gov/hiv/surveillance/resources/reports. Denning, International AIDS Society, 2010; Purcell D et al. The Open AIDS Journal, 2012, 6 (Suppl 1: M6) 98-107.
New HIV Infections (x 100,000) Faster Action Now Saves Lives and Resources Later 6 5 4 3 2 1 Stable Incidence 25% reduction in 10 years 25% reduction in 5 years 0 1 2 3 4 5 6 7 8 9 10 Years Reducing incidence by 25% In 10 years would save 62,000 infections and $23 billion In 5 years would prevent 109,000 infections and $42 billion Adapted from : Hall HI et al. J Acquir Immune Defic Syndr. 2010 Oct;55(2):271-6.
Changing Times
Some Major Recent Events Scientific breakthroughs Pre-exposure prophylaxis (PrEP) Antiretroviral therapy reduces transmission of HIV Male circumcision provides long-term reduction in risk for heterosexual men CDC released interim guidance for use of PrEP by MSM, heterosexuals, and IDUs Approved over-the-counter oral HIV test Results from studies of linkage to care, retention in care, and ART adherence Affordable Care Act expanding coverage to tens of thousands with HIV and millions at risk for HIV
Challenging Times for HIV Prevention Federal deficit ~$1.1 trillion for FY 2012 3-year freeze on federal discretionary spending Several years of reductions in public health services Loss of 46,000 state and local positions Staff furloughs, hiring freezes, pay cuts Many community organizations closed or struggling Kaiser Family Foundation; NASTAD; Center on Budget and Policy Priorities; National Coalition of STD Directors
What Do we Do Now? High Impact Prevention (HIP)
Combination Prevention Multiple Disciplines and Approaches Structural interventions Biomedical interventions HIV prevention HIV testing and linkage to care Combining interventions is not enough All interventions are not effective Community interventions Individual and small group Interventions All effective interventions are not equal Adapted from T. Coates. Lancet; 2008
Strategy Potential interventions Assess efficacy and effectiveness HIGH-IMPACT PREVENTION (HIP) Implement and evaluate programs Prioritize interventions Establish cost and cost effectiveness per infections averted and life-years saved Determine feasibility of full scale implementation Develop epidemic models to project impact of interventions
High-Impact Prevention (HIP) Applying the science of implementation to maximize impact Key components Effectiveness and cost Feasibility of full-scale implementation Coverage of targeted population Interaction and targeting Prioritizing Preventing the most HIV and reducing disparities Available for download at: www.cdc.gov/hiv/policies/hip.html
Estimated Cost per Infection Averted ($) Untargeted interventions Cost per new infection averted Testing in clinical settings 51,000 Partner services 99,000 Linkage to care 115,000 Retention in care 76,000 Adherence to ART 43,000 Targeted Interventions HET IDU MSM Testing in non-clinical settings 866,000 54,000 18,000 Behavioral intervention for HIV+ people Behavioral intervention for HIVpeople 595,000 700,000 97,000 15,600,00 2,900,000 300,000 Pre-exposure prophylaxis (PrEP) 170,000,000 900,000 700,000
HIP Can Be Applied at Every Level of Implementation Federal agencies can apply HIP to their funding of programs, surveillance, and research Jurisdictional plans for states and cities should incorporate HIP and optimize: Between buckets of $ (e.g., testing vs. individual-level program) Within buckets of $ (e.g., identify best strategy of linkage) Agencies implementing HIV prevention activities also should optimize between and within buckets CDC is trying to help the field to do this
Program and Policy Examples of HIP
What Does HIP mean for CDC? Intensify HIV prevention efforts in communities where HIV is most heavily concentrated Expand targeted efforts to prevent HIV infection using a combination of effective, evidence-based approaches for persons living with HIV and those at high risk of infection Maximize the proportion of people with HIV who have suppressed viral load by improving diagnosis, linkage and retention in care, and antiretroviral provision and adherence Improve data monitoring, dissemination, and feedback
Percent Proportion of People with HIV Diagnosed 100 80 207,600 (18% unaware) 60 40 20 0 Diagnosed Linked to care Retained in care Prescribed ART Viral Suppression One-half of new HIV transmissions come from people unaware that they have HIV
1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Number Estimated Number of Adults and Adolescents Living with HIV Infection and Percent Undiagnosed United States, 1985-2008 1,200,000 1,000,000 No. living with undiagnosed HIV infection No. living with diagnosed HIV infection Percent undiagnosed 100.0 80.0 800,000 600,000 400,000 200,000 60.0 40.0 20.0 Percent 0 0.0 Year
Return on Investment: Expanded Testing Initiative $102 million over 3 years to Health Departments For HIV testing and linkage to care in clinical and non-clinical settings: 2.8 million persons tested for HIV 18,432 (0.7%) persons newly diagnosed with HIV 3,381 HIV infections were averted $1.1 billion in direct medical costs were saved For each dollar the health system invested, $1.97 in medical costs was saved Hutchinson AB, et al. J Acquir Immune Defic Syndr. 2012 Mar 1;59(3):281-6. Return on public health investment: CDC's Expanded HIV Testing Initiative.
Aligning Resources with the Epidemic CDC Funding of State and Local Health Departments $339 million annually, allocated based on HIV prevalence Allows flexibility based on local epidemic modeling and needs Focuses on interventions that will have greatest impact on epidemic with 75% of budget focused on 4 key strategies: HIV testing, prevention with people living with HIV, policy, and condom distribution Proportion of Americans Diagnosed with HIV Who Live in Each State (2008) Proportion of CDC Core HIV Prevention Funding FY2016 2 www.cdc.gov/hiv/strategy/hihp/healthdepartments/
HD Demonstration Projects ECHPP (2010-13) Demonstration project of principles in NHAS 12 cities with most cases of HIV, representing 44% of the epidemic Planning across funding streams and 24 interventions types CAPUS (2012-15) 8 states Identify HIV-positive persons, and link, retain, and re-engage them in care by enhancing the surveillance-program feedback loop Address social determinants of health affecting identification of unknown HIV-positive persons and linking, retaining, and re-engaging them in care
CDC Rapid Feedback Reports (RFRs) Brief, regular RFRs for programmatic FOAs Health department prevention Young MSM and transgender persons of color A few easily understood indicators Feedback on progress towards goals and comparison to other grantees Provided to grantees only Attempt to reduce reporting burden, data burden, and reduce frequency of reporting
Category A Young Men of Color Who Have Sex with Men (Data from Year 1 Annual Progress Reports) Figure 1a. Number of Clients Tested for HIV Figure 1b. Percent of Clients with a New Confirmed Positive Result Figure 1c. Percent of New Positives Linked to HIV Medical Care Agencies that met or exceeded the target are depicted in black, agencies that did not meet the target are indicated in light red. The vertical line represents the minimum targets for: tests conducted (600); % of tests with a new confirmed positive result (4%); and % of new positive clients linked to HIV medical care (70%).
The Updated Compendium Risk Reduction Chapter: 74 EBIs Adherence Chapter: 8 EBIs All ILI or GLI Reviews of linkage to care (2013) and retention (2012) www.cdc.gov/hiv/topics/research/prs
Prevention Benefit Index (PBI) CDC estimated a PBI for primary prevention EBIs, considering: Real-world intervention delivery costs per person served Incidence of the target population Intervention effect size PBI compared to lifetime costs of HIV ($402,000) 23 EBIs supported by CDC were reduced to the 12 with PBIs less than 402k All key populations have at least one EBI Our prevention portfolio now focuses on those EBIs with the greatest likelihood of reducing HIV risk at the lowest costs.
High Impact HIV Surveillance Technical assistance on calculating Community Viral Load New FOA in 2013 supports: Implementation and maintenance of electronic lab reporting for all HIV-related test results Collection of CD4 cell count and viral load data as part of core surveillance activities Improving capacity to geocode surveillance data. Programmatic use of surveillance data
High Impact Surveillance: How It Works Implement policies for CD4 and viral load reporting at all levels Enhance reporting from laboratories Implement electronic lab reporting Standardize reporting elements Work with public and private labs to improve data quality Ensure reporting from healthcare providers Provide feedback to providers and patients on clinical outcomes Assist providers with re-engaging patients Implement integrated S & C policies to facilitate data sharing and ensure PII are protected Disseminate data on progress meeting indicators Monitor outcomes of viral load suppression
High Impact Surveillance Examples Louisiana Louisiana Public Health Information Exchange (LaPHIE) utilizes surveillance data to facilitate timely identification of individuals with HIV, TB or syphilis in need of follow-up and to retain them in care and in treatment Seattle 1,066 HIV patients had their records alerted through the exchange; 28 months was the average time out of care; and 81% who were out of care were linked to care Not in Care Evaluation (NOTICE) Project authorized staff review of surveillance records to identify HIV-diagnosed persons with no CD4 or VL tests reported for 12 months or with a most recent CD4 count of <500 mm3 and a VL of >500 copies/ml and to determine the primary reason for not being in care Sweeney, et al, The Milbank Quarterly, 2013
Conclusions Reduced resources and new opportunities require change HIV prevention approaches should be costeffective and should be planned using a highimpact lens CDC is implementing high impact approaches in a number of different domains Monitoring outcomes and using information to improve programs lets us know how we are doing in implementing a high impact approach National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention
Thank You! David W. Purcell, JD, PhD dpurcell@cdc.gov